Taking Proton Pump Inhibitors When You Have Arthritis

Proton pump inhibitors, also called PPI drugs, are a class of drugs that are prescribed to treat heartburn, GERD (gastroesophageal reflux disease), ulcers, or other conditions associated with excess stomach acid. Proton pump inhibitors work by blocking an enzyme that is necessary for making acid in the stomach. By blocking the enzyme, acid production decreases.

How Proton Pumps Work

The proton pump is a molecule found in some cells of the stomach (parietal cells). Acting as a molecular machine, the proton pump takes a non-acidic potassium ion out of the stomach and replaces it with an acidic hydrogen ion. By putting hydrogen ions into your stomach, the proton pump increases the acidity of your stomach contents. Stomach acid is necessary to help break down food and aid digestion.

Too much acid, though, can irritate the esophagus, causing indigestion or heartburn, and it can slow the healing of stomach ulcers. When excess acid becomes problematic, proton pump inhibitor drugs are often prescribed to shut down the proton pump.

Why Some People With Arthritis Are Prescribed PPIs

Many people with arthritis take nonsteroidal anti-inflammatory drugs (NSAIDs) to control inflammation and pain associated with their joint disease. While NSAIDs are often an effective arthritis treatment, the drugs are associated with gastrointestinal toxicity. This complication is largely due to prostaglandin inhibition by NSAIDs. People taking high dose NSAIDs or multiple NSAIDs, elderly people, or those with a history of peptic ulcer disease or gastrointestinal bleeding are at high risk for complications from NSAIDs.

To lower the risk of gastrointestinal complications, people with arthritis may be advised to take a COX-2 inhibitor (e.g., Celebrex), or a traditional NSAID (e.g., naproxen, ibuprofen) with misoprostol or a proton pump inhibitor.Misoprostol has to be taken multiple times a day, can cause diarrhea, and may cause miscarriages, premature labor, or birth defects—so, PPI drugs are typically preferred. There's also Vimovo, a drug which combines an NSAID (naproxen) and a PPI (esomeprazole) in one pill.

The combination of a PPI drug with an NSAID is not necessary in all cases. PPI drugs have actually become overused. PPI drugs, heavily advertised and promoted to both consumers and healthcare providers, have been used to treat mild stomach upset or heartburn when over-the-counter remedies, including antacids (Maalox, Mylanta, TUMS) or H2 blockers (Tagamet or Pepcid), would be sufficient.

There are conservative guidelines that help manage NSAID toxicity:

• Take only one NSAID at a time, not multiple NSAIDs.
• Use the lowest effective dose of NSAID and for the shortest duration possible.
• Do not use NSAIDs when other treatment options work (analgesics, intra-articular injection).
• Take your NSAID with food.
• Don't ignore gastrointestinal symptoms; discuss with your healthcare provider.
• People with renal insufficiency, peptic ulcer disease, gastrointestinal bleeding, aspirin/NSAID hypersensitivity, uncontrolled hypertension, or cardiovascular disease should avoid NSAIDs.

Availability

PPI drugs are available both over-the-counter and by prescription only, depending on which you choose. According to Consumer Reports, the drugs are essentially equivalent in terms of effectiveness and safety but differ in cost.

• Omeprazole (Prilosec, Prilosec OTC)
• Lansoprazole (Prevacid, Prevacid 24 hr)
• Omeprazole/sodium bicarbonate (Zegerid, Zegerid OTC)
• Pantoprazole (Protonix)
• Esomeprazole (Nexium)
• Dexlansoprazole (Kapidex)
• Rabeprazole (Aciphex)

Safety Concerns

Aside from common side effects (headache, diarrhea), there have been certain safety concerns associated with PPI drugs, such as:

• An increased risk of infection
• Increased risk of infection with the bacteria Clostridium difficile which causes severe diarrhea
• Increased risk of bone fractures, including hip fracture, with longterm use
• Reduced effectiveness of Plavix (clopidogrel) to thin the blood
• Possible interaction and lower effectiveness of other drugs and supplements

Bottom Line

No differently than for any other drug, the benefits and risks of PPIs must be weighed in each individual case. Some people may not require PPI drugs to manage mild to moderate heartburn or GERD, even though they have been prescribed the drugs. Don't stop the drugs without discussing it with your healthcare provider first. Stopping suddenly may actually increase symptoms.

People with arthritis may be able to decrease the risk of gastrointestinal toxicity associated with NSAID use without taking PPI drugs. Remember, even if PPI drugs are warranted for your specific condition, safe use implies only taking the drug for as long as it is necessary.